Family Care for Older Inpatients Reduces Delirium

Troy Brown, RN

October 22, 2019

Family members have a unique role to play when it comes to preventing postoperative delirium (POD) in elderly hospitalized patients, new data show.

The researchers adapted an existing POD prevention program typically implemented by paid and volunteer hospital staff to instead be administered by family members, and the results were striking. Far fewer patients whose family members received education and assistance in following the protocols developed POD during the first 7 days after surgery, compared with patients who received usual care.

"By having the family at the bedside, as opposed to a nurse or a volunteer, as seen in other HELP [Hospital Elder Life Program] models, patients may feel a stronger sense of security and comfort in an unfamiliar and sterile hospital surrounding," editorialists explain in an invited commentary.

The study by Yan-Yan Wang, PhD, from the Department of Geriatrics at West China Hospital, Sichuan University, Chengdu, China, and colleagues was published online October 21 in JAMA Internal Medicine.

POD occurs in 13% to 50% of older patients. The researchers estimate that 30% to 40% of those cases are preventable. Serious adverse outcomes are associated with POD, including increased length of hospital stay (LOS), mortality, risk for functional decline, and subsequent dementia.

Multicomponent nonpharmacologic interventions are the preferred approach for the prevention of delirium. "Among these approaches, the Hospital Elder Life Program (HELP) is the most widely implemented evidence-based model that targets multiple risk factors for delirium," write Wang, who is also with the School of Nursing, the University of Texas at Austin, and colleagues.

In the HELP model, hospital volunteers implement a number of interventions; however, many hospitals in China do not use volunteers. There, family members are usually more involved in caring for elderly hospitalized patients than in the United States or Europe. "This cultural background provided us with a unique, alternative resource to conduct many of the nonpharmacological interventions in HELP," the authors write.

The investigators sought to modify HELP protocols to reflect this important cultural difference and to show that HELP is effective in various healthcare systems. They called this approach t-HELP (tailored, family-involved HELP).

The two-arm, parallel-group, single-blind, cluster randomized clinical trial was conducted on six surgical floors — gastric, colorectal, pancreatic, biliary, thoracic, and thyroid. Each of those units was divided into a nursing unit that provided t-HELP or one that provided usual care. The study randomly assigned a total of 281 patients to receive either t-HELP or usual care.

The patients' mean age was 74.7 years, and more than half (60.9%; 171 patients) were men.

In the t-HELP intervention, patients underwent assessment of delirium-related risk factors within 24 hours of study enrollment or admission. Once admitted to a t-HELP unit, patients received the t-HELP protocol each day from postoperative day 1 to postoperative day 7 or discharge, if the LOS was fewer than 7 days.

Three universal protocols addressed orientation, therapeutic activities, and early mobilization. In addition, patients received eight targeted protocols that were tailored to patients on the basis of daily delirium-related assessments.

Patients' family members received family education about the importance of their involvement. Nurses observed the family members as they provided the intervention and documented each protocol as it was completed, recording reasons for nonadherence and addressing questions and concerns.

In the intention-to-treat analysis, 4 of 152 patients (2.6%) in the intervention group and 25 of 129 patients (19.4%) in the control group developed delirium, which was the primary endpoint of the trial (relative risk ([RR], 0.14; 95% confidence interval [CI], 0.05 – 0.38). The effect remained statistically significant after adjusting for age, sex, and type of surgical procedure (RR, 0.07; 95% CI, 0.02 – 0.26).

When measured by the Chinese version of the Memorial Delirium Assessment Scale, the intervention was also found to be effective at preventing delirium (two patients [1.5%] vs 11 patients [9.6%]; P = .008).

In sensitivity analysis, the difference of delirium remained significantly different, and the number needed to treat rose from 5.9 to 9.1.

In addition, patients who received the intervention experienced less physical decline with respect to activities of daily living and less cognitive decline, as measured with the Short Portable Mental Status Questionnaire. Patients in the intervention arm also had a shorter mean LOS (12.15 days vs 16.41 days; P < .001).

The proportion of patients with intact cognition rose over time in the t-HELP group but fell in the control group (proportion change, 9.7% vs –9.2%; P < .001). After adjusting for all of the covariates, the intervention "had an independent effect on cognition," the authors write.

No deaths occurred, and no adverse events were associated with the study.

Patients Were More Secure and Comfortable

Several factors may explain the success of the intervention in this study, Victoria Tang, MD, MAS, Division of Geriatrics, Department of Medicine, University of California, San Francisco, and colleagues write in their commentary.

In addition to increasing security and comfort for patients, the trust that patients have in their family member or paid caregiver may more effectively help with reality orientation and engagement in early mobilization, reducing anxiety, and enhancing sleep.

Family members may also be more mindful of keeping eyeglasses and hearing aids safe and available for patients; these are frequently not available in standard care, and patients can develop sensory deprivation and delirium as a result, the editorialists write.

Family members often assume caretaking responsibilities with little support, which can cause them to feel isolated and less confident in their ability to make a meaningful difference in the patient's recovery.

However, "[f]amily-friendly protocols can clarify expected caregiving roles for families and provide a how-to guide for delivering safe care to their hospitalized loved one," Tang and colleagues explain.

Global societal efforts that recognize the value of caretaking and the personal and economic costs experienced by caregivers are also vital, they say. The Family Medical Leave Act is helpful for protecting employment for a limited time when caregivers are unable to work but does not address the loss of income many experience.

A study found that the Program of Comprehensive Assistance for Family Caregivers ― which provides a stipend, caregiver training, and access to mental health care ― showed that better caregiver support results in decreased financial strain and improved well-being.

The results from the current study may not be generalizable, inasmuch as other cultures may not have the same level of family involvement. The authors point to the need for a culture change in US hospitals.

"Hospitals in the United States may have much to learn from other cultures in which family and caregiver engagement in patient care is the norm. Enhancing the role of these individuals in the perioperative care of patients, along with policies that support caregivers in this role, is a novel approach to reducing perioperative complications such as delirium and cognitive and physical functional decline," Tang and colleagues conclude.

JAMA Intern Med. Published online October 21, 2019. Abstract, Commentary

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